Gurpal Singh, FRCSEd(Orth)

Consultant Division of Surgical Oncology (Musculoskeletal Surgery)

National University Cancer Institute, Singapore (NCIS)

Pathologic Fractures in Osteosarcoma -

Is Limb Salvage safe?

Osteosarcoma

Kansara M, Teng MW, Smyth MJ, Thomas DM. Translational biology of osteosarcoma. Nat Rev Cancer. 2014 Nov;14(11):722-35

Quality-of-life outcome measures – limb salvage vs amputation in osteosarcoma patients

Mental component summary Social functioning Emotional role Mental health Mei J, Zhu XZ, Wang ZY, Cai XS. Functional outcomes and quality of life in patients with osteosarcoma treated with amputation versus limb-saövage surgery : a systematic review and meta analysis. Arch Orthop Trauma Surg. 2014 Nov;134(11):1507-16.

Prognostic factors

• Location of the tumour (proximal vs distal)

• Margins

• Chemotherapy response

• Tumour size

• Age of patient

• Serum alkaline phosphatase levels

• Pathological fracture?

Pathological fractures

• Prevalence: 5-10% (in literature)

• Prognostic and treatment implications are widely debated

Carefully selected patients with a pathological fracture undergoing limb salvage may have similar outcomes to those who undergo amutation in terms of

– local recurrence and

– survival compared

when

– adequately treated with nedoadjuvant and adjuvant

chemotherapy

– adequate surgical resection (margin control)

Factors to consider when advising treatment options

• Response to neoadjuvant chemotherapy

• Evidence of bony union after chemotherapy

• Involvement of soft-tissue

• Joint structures

• Neurovascular structures

• Evidence of metastases at presence

`Limb salvage surgery in the presence of a pathological fracture confers equivalent outcomes to amputation, provided margin control is adequately respected’

Relative risk with 95% confidence intervals for local recurrence between the pathological

fracture and non-fracture groups

Salunke AA, Chen Y, Tan JH, Chen X, Khin LW Puhaindran ME. Does a pathological fracture affect the prognosis in patients with osteosarcoma of hte extremities? : a systematic review and meta-analyiss. Bone Joint J. 2014 Oct;96-B(10):1396-403

Relative risk with 95% CI for local recurrence between the amputation and salvage groups in

patients with pathological fracture

Salunke AA, Chen Y, Tan JH, Chen X, Khin LW Puhaindran ME. Does a pathological fracture affect the prognosis in patients with osteosarcoma of hte extremities? : a systematic review and meta-analyiss. Bone Joint J. 2014 Oct;96-B(10):1396-403

Relative risk with 95% CI for 5-year event-free survival between the non-fracture and pahtological fracture

groups

Salunke AA, Chen Y, Tan JH, Chen X, Khin LW Puhaindran ME. Does a pathological fracture affect the prognosis in patients with osteosarcoma of hte extremities? : a systematic review and meta-analyiss. Bone Joint J. 2014 Oct;96-B(10):1396-403

Fracture and tumour characteristics in patients with pathological fractures

Salunke AA, Chen Y, Tan JH, Chen X, Khin LW Puhaindran ME. Does a pathological fracture affect the prognosis in patients with osteosarcoma of hte extremities? : a systematic review and meta-analyiss. Bone Joint J. 2014 Oct;96-B(10):1396-403

Comparison of local recurrence rates between amputation and limb salvate groups in patients

with pathological fracture

Salunke AA, Chen Y, Tan JH, Chen X, Khin LW Puhaindran ME. Does a pathological fracture affect the prognosis in patients with osteosarcoma of hte extremities? : a systematic review and meta-analyiss. Bone Joint J. 2014 Oct;96-B(10):1396-403

Our 18-year experience of high-grade osteosarcoma with a pathological fracture at

initial presentation

Methods

• Prospectively maintained osteosarcoma database

– 65 patients with primary osteosarcoma

– 17patients with pathological fractures at presentation

(1994-2012)

• mean follow-up: 3.5 ± SD3.4 years (range 8

months to 18 years)

• Demographic profile, tumour site, metastases, histologic grade, local recurrence rate, overall and event-free survival outcomes

Results

No differences in the survival and recurence rates of patients with pathological fractures compared to those with no fractures

No difference in survical between amputated and salvaged patients with fractures

Cumulative survival of fractured and non-fractured subgroups

Event-free survival of fractured and non-fractured subgroups

Results II

• The 2 groups were not comparable with respect to extent of local disease

• Resections in pathologically fractured tumours tended to be

– more extensive

– dependent less on size of tumour and

– More on preoperative radiological evaluation of extent of disease using anatomical landmarks

Results III

• 5 local recurrences – 1/15 fracture group

– 4/47 non-fracture group

• 37 lung metastasis – 10/16 fracture group

– 22/47 non-fracture group

• Positive margins – 1/14 fracture group (marginally resected)

– 10/38 non-fracture group

p = 0.11

Conclusion I

Significant high incidence of pathological fracture in osteosarcoma at initial presentation in our population (17%) as compared to current literature (5-10%)

Conclusion II

Limb salvage surgery does not confer an increased risk of distant or local failure, provided oncological principles are adhered to and margin control attempts are aggressive.

Case example of a 13 year old boy with high grade osteosarcoma of the proximal humerus

and pathological fracture at presentation.

gurpal_singh@nuhs.edu.sg

Thank you for your attention